Upper gastrointestinal bleeding resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Definition

Upper GI bleed refers to any bleeding occurring from gastrointestinal tract proximal to ligament of Treitz.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Variceal bleed
• Perforated ulcer
• Aorto-enteric fistula
• Hemosuccus pancreaticus

Any cause leading to severe gastrointestinal bleeding can be life threatening without immediate appropriate management.

Common Causes

• Angiodysplasia
• Duodenal ulcer
• Duodenitis
• Esophagitis
• Gastric ulcer
• Gastritis
• Mallory-Weiss tear
• Variceal bleed

Initial Assessment and Management

Shown below is an algorithm summarizing the approach to upper GI bleed.

Characterize the symptoms: ❑ Blood in vomiting ❑ Coffee ground emesis ❑ Black, tarry stools ❑ Frank blood in stools ❑ Maroon colored stool ❑ Abdominal pain ❑ Altered mental status ❑ Dizziness ❑ Syncope ❑ Palpitations Elicit past medical history about previous GI bleed, anticoagulants, NSAIDs, alcohol intake and other comorbities

Physical examination Abdominal examination ❑ Abdominal tenderness ❑ Involuntary guarding ❑ Bowel sounds Hyperactive: Suggests UGIB Hypoactive: Suggests mesenteric ischemia or ileus ❑ Signs of liver failure ❑ Rectal exam to assess stool color ❑ Guaiac test ❑ Blood pressure ❑ Pulse ❑ Signs of hypovolemia: Severity of blood loss Signs Mild to moderate Resting tachycardia 15% blood loss Orthostatic hypotension 40% blood loss Hypotension Shock Cold clammy extremities, Weak and thready pulse

Order tests ❑ Blood type and cross-match ❑ CBC ❑ Platelet count ❑ Prothrombin time and INR ❑ Liver enzymes ❑ BUN ❑ Creatinine ❑ Electrolytes ❑ Order EKG and cardiac enzymes to rule out myocardial infarction in elderly patients

Initial assessment ❑ Ensure normal breathing and clear airway Consider intubation in patients with ongoing massive bleeding ❑ Assess hemodynamic status ❑ Monitor vital signs ❑ Cardiac monitoring ❑ Assess mental status

Risk assessment

Patient is unstable and/or massive active bleeding and/or altered mental status

Patient is stable

❑ Consider admission to ICU after urgent initial resuscitation Initial resuscitative measures ❑ Nil per oral ❑ 2 large bore IV lines ❑ Supplemental oxygen ❑Fluid resuscitation * Administer 500 ml of NS during first 30 min and simultaneously send blood sample for cross-matching * Consider increasing fluid administration if blood pressure fails to rise ❑ Consider blood transfusion in patients with Hb < 7 g/dL ❑ Cardiac monitoring in ICU ❑ Pulse oximetry ❑ Monitor urine output ❑ Order a surgical consult

❑ Initial fluid resuscitation Blatchford score = 0 ? Blatchford Score = 0 if: ❑ Urea Nitrogen < 18.2 mg/dl ❑ Hemoglobin < 13.2 g/dL (12 g/dL for women) ❑ Systolic blood pressure > 110 mmHg ❑ Pulse <100/min ❑ Absence of melena, cardiac failure, syncope and liver disease

No

Yes

Discharge from emergency room without endoscopy

Prepare patient for early endoscopy

Endoscopic Management

Pre-endoscopic medications: ❑ Administer IV infusion of erythromycin (250 mg for 30 min) ❑ Consider IV PPI therapy (80 mg bolus followed by 8 mg/h infusion Patients with suspected varices ❑ Refer Varices and variceal bleed resident survival guide

EGD

Variceal bleed

Non variceal bleed

Refer variceal bleed

❑ Active spurting ❑ Oozing blood ❑ Non-bleeding visible vessel

Adherent Clot

❑ Clean base ulcer ❑ Flat pigmented spot

❑ Endoscopic therapy: * Thermal therapy with bipolar electrocoagulation PLUS sclerosant injection (e.g absolute alcohol) * Epinephrin injection PLUS thermal therapy or sclerotherapy or clips * Clips ❑IV PPI therapy * 80 mg bolus followed by 8 mg/hr infusion for 72 hours

❑ Consider endoscopic therapy in patients with clot resistant to irrigation ❑ IV PPI therapy

❑ No endoscopic therapy ❑ Oral PPI therapy (once daily) ❑ Regular diet after endoscopy Early prompt discharge after endoscopy in following patients: ❑ Hemodynamic stability ❑ No other comorbdity ❑ Easy access to hospital

❑ Hospital admission for 3 days ❑ Clear liquids can be fed soon after endoscopy ❑ Discharge after 3 days if no re-bleeding occurs

If re-bleeding occurs clinically

Repeat endoscopy with hemostatic therapy

Bleeding could not be controlled?

Bleeding controlled

Surgery Arterial embolization

IV PPI therapy for 72 hours Oral therapy thereafter

Above algorithm is adapted from guidelines issued by American College of Gastroenterology (ACG) and International consensus.

Long Term Prevention of Recurrent Ulcer Bleed

Patient treated for UGIB

Approach to long term treatment based on different etiologies

H. Pylori and NSAIDs

Aspirin

Idiopathic

❑ Test for H. Pylori * Endoscopic biopsy based test for H. Pylori * If biopsy is negative, confirm with a non endoscopic H. Pylori test

Is patient taking aspirin?

Continue daily PPI therapy

Treat with H. Pylori eradication therapy

Assess the indication of aspirin

Document cure of H. Pylori at > 1 month after eradication therapy is stopped with following tests: * Endoscopy (if done for some other reason) * Urea breath test * Stool antigen test

Aspirin is being given for an established cardiovascular disease (for secondary prevention)?

Aspirin is being given for primary prevention?

Is patient on NSAID or antithrombotics?

Resume aspirin as soon as possible and also start PPI therapy

Stop aspirin

No

Yes

Stop PPI therapy

❑ Stop NSAIDs. ❑ If NSAIDs have to be resumed, use celecoxib plus PPI therapy. ❑ In patients on antithrombotics, continue PPI therapy

Above algorithm is adapted from guidelines issued by American College of Gastroenterology (ACG).

Do's

• Assess hemodynamic status immediately upon presentation and start required resuscitative measures.
• Rockall score (ranging from 0-7) can be used for risk assessment. Parameters included in rockall score are systolic blood pressure, pulse, age and comorbidities.
• Administer IV PPI therapy before endoscopy to decrease the number of patients with high risk stigmata of hemorrhage, and patients requiring endoscopic therapy. However, PPI therapy do not affect the outcomes such as recurrent bleeding, surgery or death. If endoscopy is delayed for some reason, IV PPI therapy is indicated to decrease further bleeding.
• Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb> 12.0 mg/dl in women, systolic blood pressure> 110 mmHg, pulse< 100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.
• In patients with UGIB endoscopy should be considered with in 24 hours of presentation, however in patients with tachycardia, hypotension, bloody emesis should be done with in 12 hrs after presentation.
• For actively bleeding patents, thermal therapy or epinephrin therapy plus a second modality endoscopic therapy are recommended over clips and sclerosant therapy alone.
• For active bleeding on endoscopy, thermal therapy or epinephrine plus a second modality are preferred overclips or sclerosant alone.
• Epinephrine therapy, dilute epinephrine (1:10,000 or 1:20,000 in saline) and inject in doses of 0.5-2 ml in and around the bleeding site. Injections are continued until active bleeding stops.

Dont's

• Do not administer nasogastric lavage in patients with UGIB for diagnosis, prognosis, visualization or therapeutic effect.
• Do not administer epinephrine therapy alone. Always combine epinephrine therapy with a second modality.

References

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